Measuring anxiety as a treatment endpoint in youth with autism spectrum disorder

Approaches to improving mental health care for autistic children and young people: a systematic review and meta-analysis

Autistic children and young people (CYP) experience mental health difficulties but face many barriers to accessing and benefiting from mental health care. There is a need to explore strategies in mental health care for autistic CYP to guide clinical practice and future research and support their mental health needs. Our aim was to identify strategies used to improve mental health care for autistic CYP and examine evidence on their acceptability, feasibility, and effectiveness. A systematic review and meta-analysis were carried out. All study designs reporting acceptability/feasibility outcomes and empirical quantitative studies reporting effectiveness outcomes for strategies tested within mental health care were eligible. We conducted a narrative synthesis and separate meta-analyses by informant (self, parent, and clinician). Fifty-seven papers were included, with most investigating cognitive behavioral therapy (CBT)-based interventions for anxiety and several exploring service-level strategies, such as autism screening tools, clinician training, and adaptations regarding organization of services. Most papers described caregiver involvement in therapy and reported adaptations to communication and intervention content; a few reported environmental adjustments. In the meta-analyses, parent- and clinician-reported outcomes, but not self-reported outcomes, showed with moderate certainty that CBT for anxiety was an effective treatment compared to any comparison condition in reducing anxiety symptoms in autistic individuals. The certainty of evidence for effectiveness, synthesized narratively, ranged from low to moderate. Evidence for feasibility and acceptability tended to be positive. Many identified strategies are simple, reasonable adjustments that can be implemented in services to enhance mental health care for autistic individuals. Notable research gaps persist, however.

A Measurement Invariance Analysis of the Anxiety Scale for Autism-Adults in a Sample of Autistic and Non-Autistic Men and Women

The Anxiety Scale for Autism-Adults (ASA-A) captures the autistic anxiety experience, but we do not know whether it is structurally equivalent for men and women, or non-autistic people. Measurement invariance analysis considered gender and diagnostic status (342 cis-gender autistic men (N = 105) and women (N = 237), 316 cis-gender non-autistic men (N = 104) and women (N = 212)). Strict invariance was achieved between autistic men and women and between non-autistic men and women, but the ASA-A structure is quantitatively different in autistic compared to non-autistic adults. Therefore, this tool cannot be used to directly compare anxiety between these groups. Autistic women scored significantly higher on the ASA-A than autistic men and Uncertainty was the highest scoring factor for autistic participants. Future research should include alternative gender identities.

Measurement Invariance in Intellectual and Developmental Disability Research

Measurement invariance (MI) is a psychometric property of an instrument indicating the degree to which scores from an instrument are comparable across groups. In recent years, there has been a marked uptick in publications using MI in intellectual and developmental disability (IDD) samples. Our goal here is to provide an overview of why MI is important to IDD researchers and to describe some challenges to evaluating it, with an eye towards nudging our subfield into a more thoughtful and measured interpretation of studies using MI.

Examining Sensitivity to Developmental Changes on the Behavioral Inflexibility Scale

PURPOSE

The study objective was to determine if the validated Behavioral Inflexibility Scale (BIS) is sensitive to the detection of developmental changes in inflexibility in a sample of autistic children.

METHODS

Parents of autistic children (n = 146, 3-17 years) completed the BIS at two time points, one year apart, to examine change.

RESULTS

The findings indicate the BIS is sensitive to the detection of developmental changes and that child-level variables are not associated with those changes. Children's Time 1 BIS scores predicted children's severity on an independent outcome measure. Finally, a relationship between total services children were receiving and change in BIS scores over time was not found.

CONCLUSION

The findings suggest the BIS is a reasonable candidate for consideration as an outcome measure.

The Role of Maternal Anxiety in Treatment Response for Youth with ASD and Co-occurring Anxiety

Anxiety disorders occur at higher rates in youth with ASD than in neurotypical youth. Although the efficacy of CBT for anxiety in children with ASD is widely supported, factors that influence treatment outcomes are not well understood. This study examined the role of maternal anxiety in treatment outcomes for youth with ASD. Youth with ASD and anxiety (ages 8 to 14), along with their mothers (n = 87), participated in a group CBT intervention. Results indicated that maternal anxiety did not improve over the course of treatment. However, findings suggest that high levels of maternal anxiety at pre-treatment predicted higher levels of youth anxiety post-treatment. Importantly, the relationship between parent anxiety and youth outcomes was moderated by child age. The findings of the present study may provide initial insight into the role that maternal anxiety plays in treatment outcomes for children with ASD and co-occurring anxiety, particularly when considering child age.

Self and caregiver report measurement of sensory features in autism spectrum disorder: a systematic review of psychometric properties

BACKGROUND

Unusual responses to sensory stimuli are considered a diagnostic symptom of autism spectrum disorder with mounting research efforts put towards understanding, characterizing, and treating such symptoms.

METHODS

This paper examines self and caregiver report tools used to measure sensory features in ASD through a systematic review of the psychometric evidence for their use. A total of 31 empirical papers were reviewed across 20 assessment tools. Substantial differences were identified in the specific sensory features defined across assessment tools. Sensory assessment questionnaires were evaluated against quality psychometric evidence criteria to provide a use recommendation.

RESULTS

Five assessments were identified to be "appropriate with conditions," while no sensory assessment tools were identified to have sufficient quality psychometric evidence to provide a recommendation of "Appropriate" for measuring sensory features in ASD.

CONCLUSION

Evidence from this review highlights potentially significant shortcomings among the current methods used to measure sensory features in ASD and suggests the need for more efforts in developing psychometrically sound sensory assessment tools for use in ASD populations.

The lived experience of meltdowns for autistic adults

LAY ABSTRACT

There is not a lot known about what it feels like for autistic people to have a meltdown. Past research has focused on what meltdowns are like for parents and what meltdowns look like from the outside without understanding what it is like for the person having the meltdown. We asked 32 autistic adults about what it is like for them to have a meltdown. We asked them to tell us about their thoughts and feelings about having a meltdown. Then, we looked for themes in their responses that summarized the meltdown experience. Our findings showed that meltdowns hold different meaning to different people. During a meltdown, we found that most autistics described feeling overwhelmed by information, senses, and social and emotional stress. They often felt extreme emotions, such as anger, sadness, and fear, and had trouble with thinking and memory during the meltdown. Participants described trying to stay in control of themselves, often feeling like they were not themselves during meltdowns. They described the meltdown as a way of letting go of or releasing the extreme emotions they felt. Participants tried to stay away from things or people that might trigger a meltdown or tried to make sure they were alone if they felt a meltdown may be coming as a way of avoiding harm-including harm to their bodies, their emotions, and their relationships. These findings offer an important look into what it is like for autistic adults to have meltdowns from their own point of view.

Parent-Led Cognitive Behavioural Therapy for Children with Autism Spectrum Conditions. A Pilot Study

This article reports on a pilot study of a parent-only cognitive behavioural therapy (CBT) programme for parents of children with autism spectrum disorders (ASD) and anxiety difficulties. Twenty-one parents of anxious children with ASD (5-11 of age) completed the From Timid to Tiger intervention. Parent outcome measures were assessed at post-intervention and at 3-month follow-up. Analysis indicated significant reductions in both parent and clinician reports of child anxiety symptoms. Specifically, 38% of children were free of their primary diagnosis at treatment end and this increased to 57% when measured at 3-month follow-up. Positive gains were evidenced regarding parents' ability to manage their child's anxiety without accommodating to it. The results provide preliminary evidence of parent-only CBT programs for children with ASD.

Evaluation of Telehealth Delivery of Group Parent-Led Cognitive-Behavioral Therapy During COVID-19: A Pilot Study

The COVID-19 pandemic has led to governments around the world imposing varying levels of restrictions and lockdowns leading to home confinement and closure of schools. Children with autism spectrum disorder (ASD) and their families may be particularly susceptible to increased anxiety. A growing evidence base has developed for parent-led cognitive-behavioral therapy (CBT) for child anxiety disorders. The current pilot study aimed to evaluate the preliminary clinical utility (acceptability, feasibility, and efficacy) of a parent-led CBT program in Dublin, Ireland, through an online format. Parents of nine children completed the program. The child did not participate in any part of the online program. Acceptability was strong, and although technical issues were problematic at times, all families completed the program. Preliminary efficacy analysis is mixed, with significant reductions on youth anxiety as measured by clinician-administered questionnaire but no reduction in parent-report measures. Findings suggest that the online program is acceptance, feasible, and effective.

Assessment of Anxiety in Cognitive-Behavior Therapy in Young University Students with Autism Spectrum Disorders: A Review

The university provides academic support to disabled students, however, few institutions provide academic, extra-academic or preventive support to students with Autism Spectrum Disorders High-Functioning (ASD-HF). Among the most commonly requested needs is support for coping with anxiety arising from academic and social activity itself. When planning an intervention program, it is necessary to screen those who have problems and are likely to benefit from such a program. In this article we propose a systematic search for measures of anxiety for young people and adults with ASD-HF. Of a total of 683 documents, only 7 met the selection criteria. Of these, a total of 35 tools were detected, of which only 11 mediated anxiety. Screening should be carried out for all students, so that we can detect the "risk" of anxiety disturbance in all cases and, in particular, in students with ASD-HF. However, the instruments eligible for assessing intervention outcomes should be agreed upon in order to be able to compare results from different trials.

The Pediatric Autism Spectrum Therapy Observation System: Development, Psychometric Properties, and Sensitivity to Treatment

An observational coding system was developed to track clinical change in children with autism spectrum disorder (ASD) during psychotherapy. The Pediatric Autism Spectrum Therapy Observation System (PASTOS) consists of 23 items divided into 5 subscales and is used to rate child behaviors in individual psychotherapy sessions. Manual-based cognitive behavioral therapy session transcripts of 22 children diagnosed with ASD (IQ > 70) and a concurrent anxiety disorder (M = 9.41 years, SD = 1.56 years) enrolled in a randomized, controlled trial were coded. Results suggested that the PASTOS exhibited promising interrater reliability, internal consistency, convergent validity at post-treatment, and treatment sensitivity. The PASTOS may be a useful tool for studying process and outcome in psychotherapy research on children with ASD.

The Mediating Effects of Alexithymia, Intolerance of Uncertainty, and Anxiety on the Relationship Between Sensory Processing Differences and Restricted and Repetitive Behaviours in Autistic Adults

Distress caused by sensory processing differences for autistic individuals may be reduced by repetitive behaviours (RRB), including repetitive motor (RMB) and insistence on sameness (ISB) behaviours. Intolerance of uncertainty (IU) and anxiety mediate the relationship between sensory processing and RRB in autistic children. We replicated this model in autistic adults, extending it to include alexithymia. Serial mediation, using data from 426 autistic adults, identified significant direct effects from sensory processing to RMB and ISB, and indirect effects through alexithymia-IU-anxiety for RMB, and IU alone, and alexithymia-IU for ISB. Different mechanisms may underpin RMB and ISB. Alexithymia alongside, IU and anxiety, should be considered when understanding the relationship between sensory processing and RRB, and when offering interventions to support autistic people.

Integrating Measurement-Based Care into Treatment for Autism Spectrum Disorder: Insights from a Community Clinic

Measurement-based care (MBC), an evidence-based approach that has demonstrated efficacy for improving treatment outcomes, has yet to be investigated in clients with Autism Spectrum Disorder. The current paper investigates the use of MBC in autistic (n = 20) and non-autistic (n = 20) clients matched on age, sex, and presenting problem. Results of change score analysis indicated that utilizing routine symptom monitoring can enhance treatment evaluation. Autistic clients participated in significantly more sessions, made significantly less progress, and were less compliant with MBC than non-autistic clients. Though hierarchical linear modeling demonstrated no significant differences in treatment slope, results indicated moderate effect size. These results inform the use of MBC in community clinics, highlighting policy implications and need for targeted measurement.

Cognitive behavioural therapy for anxiety in children and young people on the autism spectrum: a systematic review and meta-analysis

Background

Anxiety is common in youth on the autism spectrum and cognitive behavioural therapy (CBT) has been adapted to address associated symptoms. The aim of the current systematic review and meta-analysis was to examine the efficacy of CBT for reducing anxiety in autistic youth.

Method

Searches of PubMed and Scopus databases were undertaken from January 1990 until December 2020. Studies were included if they consisted of randomised controlled trials (RCTs) using CBT to reduce anxiety in autistic youth. Separate random effects meta-analyses assessed anxiety ratings according to informant (clinician; parent; child), both at end-of-trial and at follow-up.

Results

A total of 19 RCTs met our inclusion criteria (833 participants: CBT N = 487; controls N = 346). Random effects meta-analyses revealed a large effect size for clinician rated symptoms (g = 0.88, 95% CI 0.55, 1.12, k = 11), while those for both parent (g = 0.40, 95% CI 0.24, 0.56; k = 18) and child-reported anxiety (g = 0.25, 95% CI 0.06, 0.43; k = 13) were smaller, but significant. These benefits were not however maintained at follow-up. Moderator analyses showed that CBT was more efficacious for younger children (for clinician and parent ratings) and when delivered as individual therapy (for clinician ratings). Using the Cochrane Risk of Bias 2 tool, we found concerns about reporting bias across most trials.

Conclusions

The efficacy of CBT for anxiety in autistic youth was supported in the immediate intervention period. However, substantial inconsistency emerged in the magnitude of benefit depending upon who was rating symptoms (clinician, parent or child). Follow-up analyses failed to reveal sustained benefits, though few studies have included this data. It will be important for future trials to address robustness of treatment gains overtime and to further explore inconsistency in efficacy by informant. We also recommend pre-registration of methods by trialists to address concerns with reporting bias.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-021-00658-8.

Overlap of anxiety, depression, irritability and aggressiveness in autism spectrum disorder: an exploratory study using cluster analysis

Purpose

This study aims to explore the overlap between symptoms of depression, anxiety, irritability and aggressiveness in autism spectrum disorder (ASD), to measure specific and idiosyncratic emotional responses.

Design/methodology/approach

A total of 42 high functioning adolescents and adults, between 12 and 39 years old, meeting the diagnostic and statistical manual of mental disorders – 5 criteria for ASD were selected from the InFoR Autism cohort. Data were analyzed in an exploratory way using Hill and Smith and K-medoids cluster analysis.

Findings

The authors found an aggregation of anxiety, depression, aggressive behaviors and irritability. Cluster analysis was maximized for two groups with 17 and 25 participants, respectively. The first group was characterized by high levels of symptoms of irritability, aggressiveness, hyperactivity and intermediate levels of anxiety and depression. In the first group, participants had significantly higher levels of autistic symptoms considering the social responsiveness scale and repetitive behavior scale-revised scales (relatives’ reports) suggesting that a particular group of subjects with a high level of ASD specific symptoms may express anxiety and depression in a specific way based on externalizing behaviors in addition to the common mood and anxiety symptoms.

Research limitations/implications

Improved understanding of the aggregation of externalized symptoms with symptoms of anxiety and mood disorders in ASD should lead to a better understanding of the underlying mechanisms related to emotion dysregulation in ASD.

Practical implications

Improved knowledge of the symptoms could lead to enhanced detection of psychiatric comorbidities in ASD.

Originality/value

The study was based on a transdiagnostic approach of psychiatric symptoms in individuals with ASD. Aggregation and clustering analysis was used to explore naive patterns of these psychiatric symptoms.

Protocol for targeting insomnia in school-aged children with autism spectrum disorder without intellectual disability: a randomised control trial

INTRODUCTION

Insomnia affects up to 80% of children with autism spectrum disorder (ASD). Negative consequences of insomnia in ASD include decreased quality of life (QOL), impaired learning and cognition, increased stereotypic and challenging behaviours, and increased parental stress. Cognitive behavioural treatment for childhood insomnia (CBT-CI) is a promising treatment for dealing with insomnia and its negative consequences but has not yet been studied in school-aged children with ASD and comorbid insomnia. Access to healthcare is another challenge for children with ASD, particularly in rural and underserved regions. Previous studies indicate that ASD and insomnia share common arousal-based underpinnings, and we hypothesise that CBT-CI will reduce the hyperarousal associated with insomnia and ASD. This trial will be the first to examine CBT-CI adapted for children with ASD and will provide new information about two different modes of delivery across a variety of primary and secondary child and parent sleep and related outcomes. Knowledge obtained from this trial might allow us to develop new or modify current treatments to better target childhood insomnia and ASD.

METHODS AND ANALYSIS

Children (N=180) 6-12 years of age with ASD and insomnia will be recruited from an established autism database, a paediatric clinic and community outreach in the Columbia, MO and surrounding areas. Participants will be randomised to CBT-CI adapted for children with ASD (in-person or remote using computers with cameras) or Sleep Hygiene and Related Education. Participants will be assessed at baseline, post-treatment, 6-month and 12-month follow-ups. The following assessments will be completed regarding the children: objective and subjective sleep, daytime functioning (adaptive functioning, attention, challenging behaviours, anxiety), QOL and physiological arousal (heart rate variability) and parents: objective and subjective sleep, daytime functioning (anxiety, depression, fatigue), QOL, physiological arousal and parental burden/stress.

ETHICS AND DISSEMINATION

Ethics approval was obtained in January 2020 from the University of Missouri. Ethics approval was obtained in July 2020 from the US Army Medical Research and Development Command, Office of Research Protections and Human Research Protection Office. All data are expected to be collected by 2024. Full trial results are planned to be published by 2025. Secondary analyses of baseline data will be subsequently published.

TRIAL REGISTRATION NUMBER

NCT04545606; Pre-results.

Brief Report: Caregiver Confidence in Reporting Anxiety Symptoms in Children with Autism Spectrum Disorder

Assessment of anxiety in children with autism spectrum disorder (ASD) most commonly includes parent questionnaires. However, due to the nature of the questions and verbal limitations often present in children with ASD, caregivers may have difficulty completing such measures. Caregivers of 144 children with ASD ages 6 to 12 completed the Child and Adolescent Symptom Inventory-4 ASD Anxiety Scale and rated their level of confidence in responding to each item. Results indicated that parents had a moderate to high level of confidence in rating their children's anxiety symptoms. Parent confidence was not influenced by their child's age, expressive language ability, or intellectual functioning, but was related to their child's anxiety symptom count and ASD severity.

Drug development for Autism Spectrum Disorder (ASD): Progress, challenges, and future directions

In 2017, facing lack of progress and failures encountered in targeted drug development for Autism Spectrum Disorder (ASD) and related neurodevelopmental disorders, the ISCTM with the ECNP created the ASD Working Group charged to identify barriers to progress and recommending research strategies for the field to gain traction. Working Group international academic, regulatory and industry representatives held multiple in-person meetings, teleconferences, and subgroup communications to gather a wide range of perspectives on lessons learned from extant studies, current challenges, and paths for fundamental advances in ASD therapeutics. This overview delineates the barriers identified, and outlines major goals for next generation biomedical intervention development in ASD. Current challenges for ASD research are many: heterogeneity, lack of validated biomarkers, need for improved endpoints, prioritizing molecular targets, comorbidities, and more. The Working Group emphasized cautious but unwavering optimism for therapeutic progress for ASD core features given advances in the basic neuroscience of ASD and related disorders. Leveraging genetic data, intermediate phenotypes, digital phenotyping, big database discovery, refined endpoints, and earlier intervention, the prospects for breakthrough treatments are substantial. Recommendations include new priorities for expanded research funding to overcome challenges in translational clinical ASD therapeutic research.

Novel treatments for autism spectrum disorder based on genomics and systems biology

BACKGROUND

Autism spectrum disorder (ASD) is a highly heterogeneous neurodevelopmental disorder with a complex underlying genetic architecture. There are currently no known pharmacologic treatments for the core ASD symptoms of social deficits and restricted/ repetitive behavior. However, there are dozens of clinical trials currently underway that are testing the impact of novel and existing agents on core and associated symptoms in ASD.

METHODS

We present a narrative synthesis of the historical and contemporary challenges to drug discovery in ASD. We then provide an overview of novel treatments currently under investigation from a genomics and systems biology perspective.

RESULTS

Data driven network and cluster analyses suggest alterations in transcriptional regulation, chromatin remodelling, synaptic transmission, neuropeptide signalling, and/or immunological mechanisms may contribute to or underlie the development of ASD. Agents and upcoming trials targeting each of the above listed systems are reviewed.

CONCLUSION

Identifying effective pharmacologic treatments for the core and associated symptom domains in ASD will require further collaboration and innovation in the areas of outcome measurement, biomarker research, and genomics, as well as systematic efforts to identify and treat subgroups of individuals with ASD who may be differentially responsive to specific treatments.

Caution When Screening for Autism among Socially Anxious Youth

Social anxiety disorder (SAD) is commonly comorbid with autism spectrum disorder (ASD). Here, in a sample of 86 children and adolescents (MAGE = 12.62 years; 68.6% male), 28 of whom were diagnosed with ASD, 34 with SAD, and 24 with comorbid ASD and SAD, we compared parent-reported scores from the Social Responsiveness Scale-Second Edition (SRS-2; Constantino and Gruber in Social Responsiveness Scale (SRS; Constantino and Gruber 2012) to determine the sensitivity and specificity of the measure in cases of differential diagnosis between SAD and ASD. Results suggest that neither the subscales, nor the SRS-2 total score, consistently differed between ASD and SAD. Sensitivity and specificity analyses suggested that the SRS-2 total poorly discriminated ASD from SAD. When screening socially anxious youth for possible ASD, caution should be taken.

The Additive Effect of CBT Elements on the Video Game 'Mindlight' in Decreasing Anxiety Symptoms of Children with Autism Spectrum Disorder

The aim of the present study was to examine the additive effect of elements of cognitive behavioral therapy (CBT) on the video game Mindlight in decreasing anxiety of children with an autism spectrum disorder (ASD). A non-concurrent multiple baseline design with 8 children with ASD in the age of 8–12 was used. CBT did not have the hypothesized additive effect on Mindlight in decreasing anxiety of children with ASD. Instead, multiple participants already experienced a decrease in anxiety during the Mindlight sessions. Yet, several participants did experience a stabilization in anxiety at a low level during the CBT sessions. For now, it can be concluded that CBT does not have an additive effect on Mindlight.

Critical aspects of neurodevelopment

Organisms have the unique ability to adapt to their environment by making use of external inputs. In the process, the brain is shaped by experiences that go hand-in-hand with optimisation of neural circuits. As such, there exists a time window for the development of different brain regions, each unique for a particular sensory modality, wherein the propensity of forming strong, irreversible connections are high, referred to as a critical period of development. Over the years, this domain of neurodevelopmental research has garnered considerable attention from many scientists, primarily because of the intensive activity-dependent nature of development. This review discusses the cellular, molecular, and neurophysiological bases of critical periods of different sensory modalities, and the disorders associated in cases the regulators of development are dysfunctional. Eventually, the neurobiological bases of the behavioural abnormalities related to developmental pathologies are discussed. A more in-depth insight into the development of the brain during the critical period of plasticity will eventually aid in developing potential therapeutics for several neurodevelopmental disorders that are categorised under critical period disorders.

Qualitative evaluation of the Autism Behavior Inventory: use of cognitive interviewing to establish validity of a caregiver report scale for autism spectrum disorder

PURPOSE

The Autism Behavior Inventory (ABI) is an observer-reported outcome scale measuring core and associated features of autism spectrum disorder (ASD). Extensive scale development (reported elsewhere) took place, in alignment with the Food and Drug Administration's patient-reported outcome guidance, to address the need for instruments to measure change and severity of ASD symptoms.

METHODS

Cognitive interviewing was used to confirm understanding and content validity of the scale prior to its use in clinical trials. Respondents were caregivers of individuals with ASD (N = 50). Interviews used a hybrid of the "think-aloud" and verbal probing approach to assess ABI's content validity and participant understanding of the instrument, including: item clarity and relevance; item interpretation; appropriateness of response scales; and clarity of instructions. Audio-recordings of the interviews were transcribed for qualitative data analysis. The scale was revised based on participant feedback and tested in a second round of interviews (round 1 N = 38, round 2 N = 12).

RESULTS

In total, 67/70 items reached ≥ 90% understandability across participants. Caregivers were able to select an appropriate response from the options available and reported finding the examples helpful. Based on participant feedback, instructions were simplified, 8 items were removed, and 10 items were reworded. The final revised 62-item scale was presented in round 2, where caregivers reported readily understanding the instructions, response options, and 61/62 items reached ≥ 90% understandability.

CONCLUSIONS

Cognitive interviews with caregivers of a diverse sample of individuals with ASD confirm the content validity and relevance of the ABI to assess core and associated symptoms of ASD.

Psychiatric assessment

Studies have consistently reported an increased prevalence of psychiatric comorbidity (PC) in individuals with neurodevelopmental disorders (NDDs) compared with typically developing controls, with high rates of anxiety disorders in autism spectrum disorders and challenging behaviors in children and adolescent with intellectual disability. Psychiatric assessment in this population should include multiple sources of information, derived from multiple contexts and using multiple methods, with accurate detection of contributing and trigger factors. It is important to focus on detecting change from the child's baseline functioning and to use, when possible, ad hoc instruments for assessing PC in the NDD population. Modifications in the setting and assessment procedures should be scheduled based on the child's age, developmental level, and sensory sensitivities. Simultaneously, validated screening instruments, which dimensionally assess the symptomatology of several NDDs and psychiatric disorders, are warranted to not only assist in the identification of PCs in NDDs but also discriminate among different NDDs. Changes from DSM-IV-TR to DSM-5 have had an impact on the diagnosis of several disorders in children and adolescents and, subsequently, on the current diagnostic tools, requiring appropriate and prompt modifications of the available instruments.

The Impact of Comorbidity on Cognitive-Behavioral Therapy Response in Youth with Anxiety and Autism Spectrum Disorder

The impact of externalizing comorbidity on treatment outcome was examined in 104 youth ages 7-16 (M = 11.09 years) with autism spectrum disorder and primary anxiety/obsessive compulsive disorder who completed modular cognitive behavioral therapy (CBT) for anxiety/OCD. Three comorbidity profiles were utilized for group comparisons: participants with oppositional defiant or conduct disorder with attention-deficit hyperactivity disorder (ODD; CD; ADHD; group EXT, n = 25); those without ODD/CD and only ADHD (group ADHD, n = 46); and those without externalizing comorbidity (NO-EXT, n = 33). Post-treatment outcomes were measured continuously (Pediatric Anxiety Rating Scale, Clinical Global Impression-Severity) and categorically (treatment response, remission). The ADHD group was four times more likely of being a treatment responder compared to NO-EXT (OR 4.05). Comorbidity group did not impact remission. After controlling for pre-treatment scores, there was a significantly greater reduction of the CGI-S for ADHD versus NO-EXT and EXT versus NO-EXT, but results did not significantly differ for the PARS. Results suggest that a modular CBT approach yields positive impact for treatment outcomes in youth with comorbid externalizing problems, particularly among those with comorbid ADHD.

Social Communication Symptoms in Children With Autism Spectrum Disorder: Predicting Comorbid Anxiety Disorder

Relatively few measures have been examined for their psychometric properties when assessing anxiety among children with autism spectrum disorder (ASD), and the relationship between ASD and anxiety symptoms remains poorly understood. This study examined the relationship between ASD symptoms on the Social Responsiveness Scale ( SRS) and comorbid clinical anxiety. In a sample of 2,435 participants, parents of children with ASD and comorbid anxiety endorsed more frequent or severe ASD symptoms than parents of children without comorbid anxiety. Severity of ASD symptoms was a significant predictor of anxiety status and approached clinical significance. Implications for measurement of anxiety among children with ASD are discussed, including that areas of symptom presentation should be carefully evaluated, and that the onset or worsening of anxiety may affect ASD symptom presentation.

A Pilot Study of Cardiovascular Reactivity in Children With Autism Spectrum Disorder

In preparation for a larger case-control study of children with autism spectrum disorder (ASD) and anxiety, we conducted a pilot study using a noninvasive electrocardiographic device to measure cardiovascular reactivity in 10 children (age range 9-14) with ASD. The 45-minute procedure included 6 conditions: baseline rest, an interview about school, interim rest, an unfair computerized ball-toss game followed by a fair version of the game, and a final rest. Data were successfully collected for 95% of all conditions. Omnibus Skillings-Mack tests suggested that heart rate variability variables including mean heart rate, mean RR interval, and root mean square of successive differences showed statistically significant variation across conditions. The procedure appears feasible and may be an informative biomarker of anxiety in ASD.

Reliability and validity of the Pediatric Anxiety Rating Scale modified for autism spectrum disorder

LAY ABSTRACT

Many youth with autism spectrum disorder have anxiety, but it can be difficult to assess anxiety with existing measures. We modified the Pediatric Anxiety Rating Scale for youth with autism spectrum disorder and tested the new measure in a group of 116 youth (age: 5-17 years) with autism spectrum disorder. The Pediatric Anxiety Rating Scale for youth with autism spectrum disorder is an interview that a clinician usually completes with the child and parent together. We modified the interview questions and scoring instructions based on feedback from parents of children with autism spectrum disorder and from a panel of experts in autism spectrum disorder and anxiety. Unlike many other anxiety measures, the Pediatric Anxiety Rating Scale for youth with autism spectrum disorder relies less on a child's verbal expression of anxiety and more on signs that a parent can easily observe. Training clinicians to administer and score the Pediatric Anxiety Rating Scale for youth with autism spectrum disorder was uncomplicated, and raters showed excellent agreement on video-recorded interviews. Youth who were not currently in treatment for anxiety had stable Pediatric Anxiety Rating Scale for youth with autism spectrum disorder scores with repeat measurement over a 1-month period. The Pediatric Anxiety Rating Scale for youth with autism spectrum disorder is a useful clinician-rated measure of anxiety in youth with autism spectrum disorder and fills a gap for assessing anxiety in this population.

The Sensory Abnormalities and Neuropsychopathology of Autism and Anxiety

Autism spectrum disorder (ASD) is a developmental disorder of interpersonal communications and restricted interest and deficits in sensory and social interactions. It co-occurs with anxiety and mostly in 30% of cases related to specific phobia. This review article summarises the sensory association between anxiety and ASD. The role of emotions and neurobiology discussed and sensory over-reactivity (SOR) was related to ASD and anxiety. PubMed database systematically searched for related articles on ASD and anxiety. The keywords used are autism spectrum disorder, autism spectrum disorder and emotion, anxiety disorder, sensory in autism and anxiety, and psychopathology. The results were most significant and related to the sensory association between ASD and anxiety. Out of 19 studies discussed, there were eight systematic reviews with meta-analysis, seven systematic reviews, three traditional reviews, and one included both systematic reviews with randomized controlled trials (RCTs). However, due to possible limitations and considerations, like small sample size and few clinical trials; hence, further recommendations to randomized clinical trials and cohort studies warranted. This review article helps scientists to plan and focus on necessary studies and possible screening for the disease to improve possible clinical outcomes. People gain awareness of the disease. Early recognition, as well as educational, behavioral, and family therapy, might decrease symptoms and support learning and development in children.

Relationship Between Sleep and Behavior in Autism Spectrum Disorder: Exploring the Impact of Sleep Variability

Objective

The relationship between sleep (caregiver-reported and actigraphy-measured) and other caregiver-reported behaviors in children and adults with autism spectrum disorder (ASD) was examined, including the use of machine learning to identify sleep variables important in predicting anxiety in ASD.

Methods

Caregivers of ASD (n = 144) and typically developing (TD) (n = 41) participants reported on sleep and other behaviors. ASD participants wore an actigraphy device at nighttime during an 8 or 10-week non-interventional study. Mean and variability of actigraphy measures for ASD participants in the week preceding midpoint and endpoint were calculated and compared with caregiver-reported and clinician-reported symptoms using a mixed effects model. An elastic-net model was developed to examine which sleep measures may drive prediction of anxiety.

Results

Prevalence of caregiver-reported sleep difficulties in ASD was approximately 70% and correlated significantly (p < 0.05) with sleep efficiency measured by actigraphy. Mean and variability of actigraphy measures like sleep efficiency and number of awakenings were related significantly (p < 0.05) to ASD symptom severity, hyperactivity and anxiety. In the elastic net model, caregiver-reported sleep, and variability of sleep efficiency and awakenings were amongst the important predictors of anxiety.

Conclusion

Caregivers report problems with sleep in the majority of children and adults with ASD. Reported problems and actigraphy measures of sleep, particularly variability, are related to parent reported behaviors. Measuring variability in sleep may prove useful in understanding the relationship between sleep problems and behavior in individuals with ASD. These findings may have implications for both intervention and monitoring outcomes in ASD.

What are we targeting when we treat autism spectrum disorder? A systematic review of 406 clinical trials

The number of trials aimed at evaluating treatments for autism spectrum disorder has been increasing progressively. However, it is not clear which outcome measures should be used to assess their efficacy, especially for treatments which target core symptoms. The present review aimed to provide a comprehensive overview regarding the outcome measures used in clinical trials for people with autism spectrum disorder. We systematically searched the Web of KnowledgeSM database between 1980 and 2016 to identify published controlled trials investigating the efficacy of interventions in autism spectrum disorder. We included 406 trials in the final database, from which a total of 327 outcome measures were identified. Only seven scales were used in more than 5% of the studies, among which only three measured core symptoms (Autism Diagnostic Observation Schedule, Childhood Autism Rating Scale, and Social Responsiveness Scale). Of note, 69% of the tools were used in the literature only once. Our systematic review has shown that the evaluation of efficacy in intervention trials for autism spectrum disorder relies on heterogeneous and often non-specific tools for this condition. The fragmentation of tools may significantly hamper the comparisons between studies and thus the discovery of effective treatments for autism spectrum disorder. Greater consensus regarding the choice of these measures should be reached.

Development of the Behavioral Inflexibility Scale for Children with Autism Spectrum Disorder and Other Developmental Disabilities

Behavior inflexibility (BI) refers to rigid patterns of behavior that contrast with the need to be adaptable to changing environmental demands. We developed a parent-reported outcome measure of BI for children with autism spectrum disorder (ASD) and other developmental disabilities with a multi-step iterative process. A pool of 62 candidate items was generated through expert panel feedback, review of existing scales and focus groups. A consensus process was used to generate the final 38 items. Parents of 943 children (age range, 3-18 years; average, 11.4 years; 79% boys) with ASD completed an online survey. One hundred thirty-three parents rated their child twice within 3 weeks (average = 16.5 days). A series of factor analyses suggested that the 38 items measured a single construct. Scores had a weak correlation with level of functioning (-0.12) and did not differ based on sex. Scores had a negligible correlation with age (-0.07), although measurement invariance was not supported. The mean total score for the Behavioral Inflexibility Scale (BIS) was normally distributed. Internal consistency was α = 0.97 and temporal stability was r = 0.92. Correlations with parent ratings on the subscales of the Repetitive Behavior Scale-Revised varied from 0.48 to 0.89. The correlation with parent ratings on the Social Communication Questionnaire total score was 0.52. Our data show that BI in children with ASD ranges significantly from mild to severe and that the 38-item BIS is valid and reliable. Autism Res 2020, 13: 489-499. © 2020 The Authors. Autism Research published by International Society for Autism Research published by Wiley Periodicals, Inc. LAY SUMMARY: We developed a parent-completed rating scale of behavior inflexibility (BI) for children with developmental disabilities using a multistep process. The Behavioral Inflexibility Scale (BIS) contains 38 questions rated on a 6-point scale. Parents of 943 children with autism spectrum disorder (ASD) completed an online survey. We examined associations between the BIS and other scales and demographic variables. The BIS is valid and reliable. BI in children with ASD ranges from mild to severe.

Association of Comorbid Mood and Anxiety Disorders With Autism Spectrum Disorder

IMPORTANCE

It is critical to evaluate the risk of comorbid psychiatric diagnoses to meet the needs of individuals with autism spectrum disorder (ASD).

OBJECTIVE

To examine whether individuals with ASD are at greater risk for comorbid diagnoses of depression, anxiety, or bipolar disorder.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from a population-based birth cohort of 31 220 individuals born in Olmsted County, Minnesota, from January 1, 1976, to December 31, 2000. Patients with research-identified ASD were previously identified using a multistep process that evaluated signs and symptoms abstracted from medical and educational records. For each of the 1014 patients with ASD, 2 age- and sex-matched referents who did not meet criteria for ASD were randomly selected from the birth cohort (n = 2028). Diagnosis codes for anxiety, depression, and bipolar disorders were electronically obtained using the Rochester Epidemiological Project records-linkage system. Data analysis was performed from July 1, 2018, to April 1, 2019.

MAIN OUTCOMES AND MEASURES

Cumulative incidence of clinically diagnosed depression, anxiety, and bipolar disorder through early adulthood in individuals with ASD compared with referents.

RESULTS

A total of 1014 patients with ASD (median age at last follow-up, 22.8 years [interquartile range, 18.4-28.0 years]; 747 [73.7%] male; 902 [89.0%] white) and 2028 referents (median age at last follow-up, 22.4 years [interquartile range, 18.8-26.2 years]; 1494 [73.7%] male; 1780 [87.8%] white) participated in the study. Patients with ASD were significantly more likely to have clinically diagnosed bipolar disorder (hazard ratio [HR], 9.34; 95% CI, 4.57-19.06), depression (HR, 2.81; 95% CI, 2.45-3.22), and anxiety (HR, 3.45; 95% CI, 2.96-4.01) compared with referents. Among individuals with ASD, the estimates of cumulative incidence by 30 years of age were 7.3% (95% CI, 4.8%-9.7%) for bipolar disorder, 54.1% (95% CI, 49.8%-58.0%) for depression, and 50.0% (95% CI, 46.0%-53.7%) for anxiety. Among referents, cumulative incidence estimates by 30 years of age were 0.9% (95% CI, 0.1%-1.7%) for bipolar disorder, 28.9% (95% CI, 25.7%-32.0%) for depression, and 22.2% (95% CI, 19.3%-25.0%) for anxiety.

CONCLUSIONS AND RELEVANCE

The findings suggest that individuals with ASD may be at increased risk for clinically diagnosed depression, anxiety, and bipolar disorder compared with age- and sex-matched referents. This study supports the importance of early, ongoing surveillance and targeted treatments to address the psychiatric needs of individuals with ASD.

Anxiety in young people with autism spectrum disorder: Common and autism-related anxiety experiences and their associations with individual characteristics

Anxiety is common in autism spectrum disorder. Many anxiety symptoms in autism spectrum disorder are consistent with Diagnostic and Statistical Manual of Mental Disorders (5th ed.) anxiety disorders (termed "common" anxieties), but others may be qualitatively different, likely relating to autism spectrum disorder traits (herein termed "autism-related" anxieties). To date, few studies have examined both "common" and "autism-related" anxiety experiences in autism spectrum disorder. We explored caregiver-reported Spence Children's Anxiety Scale-Parent version data from a multi-site (United Kingdom, Singapore, and United States) pooled database of 870 6- to 18-year-old participants with autism spectrum disorder, of whom 287 provided at least one written response to the optional open-ended Spence Children's Anxiety Scale-Parent item 39 ("Is there anything else your child is afraid of?"). Responses were thematically coded to explore (a) common and autism-related anxiety presentations and (b) their relationship with young people's characteristics. Nearly half of the responses were autism-related anxieties (mostly sensory, uncommon, or idiosyncratic specific phobias and worries about change and unpredictability). The other half described additional common anxieties not covered in the original measure (mostly social, weather and environmental disasters, and animals). Caregivers of participants who were more severely affected by autism spectrum disorder symptoms reported more autism-related, as compared to common, additional anxieties. Implications for the assessment and understanding of anxiety in autism are discussed.

Exploring Anxiety at Home, School, and in the Community Through Self-Report From Children on the Autism Spectrum

Research investigating anxiety in children on the autism spectrum usually reports caregiver rather than self-report perspectives. This study aimed to document children's own descriptions of their anxiety symptomatology by combining profiles on a standardized autism-specific self-report measure of anxiety (ASC-ASD-C) with the answers from closed- and open-answer questions about anxiety across home, school, and community settings. Across the sample of 113 children on the spectrum aged 6-14 years, the two most frequently endorsed items on the ASC-ASD-C were from the Uncertainty and Performance Anxiety subscales, and the least endorsed were both from the Anxious Arousal subscale. Almost all (96.5%) of the children on the spectrum reported experiencing anxiety in at least one setting, with 40.7% reporting anxiety in all three contexts (home, school, and community). Approximately half of the sample felt their anxiety goes unrecognized by others at school and almost 60% felt it was unrecognized by others when out in the community. The proportion of children reporting having someone to help reduce their anxiety differed across home (86%), school (76%), and community (45%) settings. This highlights the importance of understanding anxiety and its impact, not only within the context of autism but also for each particular child. Autism Res 2020, 13: 603-614. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: There has been a lot of research focusing on anxiety and autism, but most of it has used parent reports, rather than asking the child themselves. This study summarizes data from 113 children on the autism spectrum, aged 6-14 years. It reports the symptoms of anxiety that these children most and least commonly experience. The results suggest only 40-50% of children feel that others are able to recognize their anxiety at school and when out in the community, suggesting that more training is needed to help adults in these settings to recognize and support anxiety.

Development of the Parent-Rated Anxiety Scale for Youth With Autism Spectrum Disorder

OBJECTIVE

Anxiety is common in youth with autism spectrum disorder (ASD). There is no accepted outcome measure for anxiety in this population.

METHOD

Following a series of focus groups with parents of youth with ASD, we generated 72 items (scored 0-3). Parents of 990 youth with ASD (aged 5-17 years; 80.8% male) completed an online survey. Factor analysis and item response theory analyses reduced the content to a single factor with 25 items. Youth with at least mild anxiety (n = 116; aged 5-17 years; 79.3% male) participated in a comprehensive clinical assessment to evaluate the validity and reliability of the 25-item Parent-Rated Anxiety Scale for ASD (PRAS-ASD).

RESULTS

In the online sample, the mean PRAS-ASD score was 29.04 ± 14.9 (range, 0-75). The coefficient α was 0.93. The item response theory results indicated excellent reliability across a wide range of scores with low standard errors. In the clinical sample (n = 116), the PRAS-ASD mean was 31.0 ± 15.6 (range, 1-65). Pearson correlations with parent ratings of ASD symptom severity, repetitive behavior, and disruptive behavior ranged 0.33 to 0.66, supporting divergent validity of the PRAS-ASD. Pearson correlation with a parent-rated measure of anxiety used in the general pediatric population of 0.83 supported convergent validity. A total of 40 participants (32 boys, 8 girls; mean age, 11.9 ± 3.4 years) returned at time 2 (mean, 12.2 days) and time 3 (mean, 24.2 days). Intraclass correlation showed test-retest reliabilities of 0.88 and 0.86 at time 2 and time 3, respectively.

CONCLUSION

The 25-item PRAS-ASD is a reliable and valid scale for measuring anxiety in youth with ASD.

Anxiety in 3- to 7-year-old children with autism spectrum disorder seeking treatment for disruptive behavior

Anxiety is a common and impairing problem in children with autism spectrum disorder, but little is known about it in preschool children with autism spectrum disorder. This article reports on the characteristics of anxiety symptoms in young children with autism spectrum disorder using a parent-completed rating scale. One hundred and eighty children (age 3-7 years) participated in a clinical trial of parent training for disruptive behaviors. Anxiety was measured as part of pre-treatment subject characterization with 16 items from the Early Childhood Inventory, a parent-completed scale on child psychiatric symptoms. Parents also completed other measures of behavioral problems. Sixty-seven percent of children were rated by their parents as having two or more clinically significant symptoms of anxiety. There were no differences in the Early Childhood Inventory anxiety severity scores of children with IQ < 70 and those with ⩾70. Higher levels of anxiety were associated with severity of oppositional defiant behavior and social disability. Anxiety symptoms are common in preschoolers with autism spectrum disorder. These findings are consistent with earlier work in school-age children with autism spectrum disorder. There were no differences in anxiety between children with IQ below 70 and those with IQ of 70 and above. Social withdrawal and oppositional behavior were associated with anxiety in young children with autism spectrum disorder.

Brief Report: Self-Reported Academic, Social, and Mental Health Experiences of Post-Secondary Students with Autism Spectrum Disorder

Increasing numbers of individuals with autism spectrum disorder (ASD) are enrolling in post-secondary academic institutions. However, research indicates that post-secondary students with ASD are struggling more than their typically developing peers, with high rates of loneliness, anxiety, depression, and an increased incidence of dropping-out before completion of their degrees. The current study utilized an online survey to gain insight into the self-reported academic, social, and mental health experiences of post-secondary students with ASD. Participants reported high levels of academic comfort, but struggled with issues of isolation/loneliness and high levels of stress, anxiety, and depression. Of greatest concern, were the nearly three-quarters of participants who reported lifetime suicidal behaviors. Further analysis on collected data and implications of findings are discussed.

Caregiver Daily Reporting of Symptoms in Autism Spectrum Disorder: Observational Study Using Web and Mobile Apps

BACKGROUND

Currently, no medications are approved to treat core symptoms of autism spectrum disorder (ASD). One barrier to ASD medication development is the lack of validated outcome measures able to detect symptom change. Current ASD interventions are often evaluated using retrospective caregiver reports that describe general clinical presentation but often require recall of specific behaviors weeks after they occur, potentially reducing accuracy of the ratings. My JAKE, a mobile and Web-based mobile health (mHealth) app that is part of the Janssen Autism Knowledge Engine-a dynamically updated clinical research system-was designed to help caregivers of individuals with ASD to continuously log symptoms, record treatments, and track progress, to mitigate difficulties associated with retrospective reporting.

OBJECTIVE

My JAKE was deployed in an exploratory, noninterventional clinical trial to evaluate its utility and acceptability to monitor clinical outcomes in ASD. Hypotheses regarding relationships among daily tracking of symptoms, behavior, and retrospective caregiver reports were tested.

METHODS

Caregivers of individuals with ASD aged 6 years to adults (N=144) used the My JAKE app to make daily reports on their child's sleep quality, affect, and other self-selected specific behaviors across the 8- to 10-week observational study. The results were compared with commonly used paper-and-pencil scales acquired over a concurrent period at regular 4-week intervals.

RESULTS

Caregiver reporting of behaviors in real time was successfully captured by My JAKE. On average, caregivers made reports 2-3 days per week across the study period. Caregivers were positive about their use of the system, with over 50% indicating that they would like to use My JAKE to track behavior outside of a clinical trial. More positive average daily reporting of overall type of day was correlated with 4 weekly reports of lower caregiver burden made at 4-week intervals (r=-0.27, P=.006, n=88) and with ASD symptoms (r=-0.42, P<.001, n=112).

CONCLUSIONS

My JAKE reporting aligned with retrospective Web-based or paper-and-pencil scales. Use of mHealth apps, such as My JAKE, has the potential to increase the validity and accuracy of caregiver-reported outcomes and could be a useful way of identifying early changes in response to intervention. Such systems may also assist caregivers in tracking symptoms and behavior outside of a clinical trial, help with personalized goal setting, and monitoring of progress, which could collectively improve understanding of and quality of life for individuals with ASD and their families.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02668991; https://clinicaltrials.gov/ct2/show/NCT02668991.

Clinical Validation of the Autism Behavior Inventory: Caregiver-Rated Assessment of Core and Associated Symptoms of Autism Spectrum Disorder

There is a need for measures to track symptom change in autism spectrum disorder (ASD). We conducted a validation study on a revised version of the Autism Behavior Inventory (ABI), and a short form (ABI-S). Caregivers of individuals (6–54 years) with confirmed diagnoses of ASD (N = 144) completed the ABI and other rating scales at 4 time points. Scale consistency for each domain, 3–5 day test–retest reliability, and construct validity, determined by comparison to pre-specified scales, were all good. Change in the ABI was congruent with changes in other instruments. Collectively, results suggest incipient suitability of the ABI as a measure of changes in core and associated symptoms of ASD.

Trial Registration NCT02299700.

An Observational Study With the Janssen Autism Knowledge Engine (JAKE®) in Individuals With Autism Spectrum Disorder

Objective: The Janssen Autism Knowledge Engine (JAKE®) is a clinical research outcomes assessment system developed to more sensitively measure treatment outcomes and identify subpopulations in autism spectrum disorder (ASD). Here we describe JAKE and present results from its digital phenotyping (My JAKE) and biosensor (JAKE Sense) components. Methods: An observational, non-interventional, prospective study of JAKE in children and adults with ASD was conducted at nine sites in the United States. Feedback on JAKE usability was obtained from caregivers. JAKE Sense included electroencephalography, eye tracking, electrocardiography, electrodermal activity, facial affect analysis, and actigraphy. Caregivers of individuals with ASD reported behaviors using My JAKE. Results from My JAKE and JAKE Sense were compared to traditional ASD symptom measures. Results: Individuals with ASD (N = 144) and a cohort of typically developing (TD) individuals (N = 41) participated in JAKE Sense. Most caregivers reported that overall use and utility of My JAKE was "easy" (69%, 74/108) or "very easy" (74%, 80/108). My JAKE could detect differences in ASD symptoms as measured by traditional methods. The majority of biosensors included in JAKE Sense captured sizable amounts of quality data (i.e., 93-100% of eye tracker, facial affect analysis, and electrocardiogram data was of good quality), demonstrated differences between TD and ASD individuals, and correlated with ASD symptom scales. No significant safety events were reported. Conclusions: My JAKE was viewed as easy or very easy to use by caregivers participating in research outside of a clinical study. My JAKE sensitively measured a broad range of ASD symptoms. JAKE Sense biosensors were well-tolerated. JAKE functioned well when used at clinical sites previously inexperienced with some of the technologies. Lessons from the study will optimize JAKE for use in clinical trials to assess ASD interventions. Additionally, because biosensors were able to detect features differentiating TD and ASD individuals, and also were correlated with standardized symptom scales, these measures could be explored as potential biomarkers for ASD and as endpoints in future clinical studies. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT02668991 identifier: NCT02668991.

Clinical trials in autism spectrum disorder: evidence, challenges and future directions

PURPOSE OF REVIEW

The purpose of this manuscript is to review the evidence generated by clinical trials of pharmaceuticals in autism spectrum disorder (ASD), describe challenges in the conduct of such trials, and discuss future directions RECENT FINDINGS: Clinical trials in ASD have produced several compounds to adequately support the pharmacological treatment of associated symptom domains: attention deficit hyperactivity disorder (methylphenidate, atomoxetine, and alpha agonists), irritability/aggression (risperidone and aripiprazole), sleep (melatonin), and weight gain associated with atypical antipsychotic use (metformin). However, there is no evidence yet to support the routine use of pharmaceuticals for the treatment of core symptom domains. Challenges in the field include biological heterogeneity within ASD, lack of biomarkers that clarify biological heterogeneity or predict response to treatment, lack of data across the lifespan, and suboptimal outcome measures.

SUMMARY

Several compounds have evidence for the treatment of co-occurring symptoms in children and youth with ASD, although pharmacological interventions for core symptoms are still lacking. Identifying the various biologies underling ASD and developing biomarkers that stratify biologically homogeneous populations are both necessary to realize the promise of precision medicine in ASD.